Healthcare Provider Details

I. General information

NPI: 1821252800
Provider Name (Legal Business Name): AMANDA LEA LOVOLD DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2008
Last Update Date: 08/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 WHITNEY CT CENTRACARE CLINIC-HEARTLAND FAMILY MEDICINE
ST CLOUD MN
56703-1899
US

IV. Provider business mailing address

1520 WHITNEY CT CENTRACARE CLINIC-HEARTLAND FAMILY MEDICINE
ST CLOUD MN
56703-1899
US

V. Phone/Fax

Practice location:
  • Phone: 320-251-1775
  • Fax:
Mailing address:
  • Phone: 320-251-1775
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number51987
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: